152-Wk9 Text P&p Ch. 31 Part A (494-520)-Jannah U-C

Front 1

When do you measure vital signs?

Back 1

-Complete physical assessment (provides a baseline for further assessments)
- client's considtions determines when, where, how and by whom vital signs are measured

Front 2

What are some guidelines for measuring vital signs?

(see p. 494 for full descriptions)

Back 2

-unregulated care providers may measure selected vital signs (and nurse responsible may interpret and act on these measurements)
- use appropriate and functional equipment
-select equipment based on client's condition and characteristics
-minimize environmental factors that may affect vital signs
-use organized approach
-use baseline measurements to compare
-develop teaching plan to instruct client of caregiver on vital sign asssessment

Front 3

Normal vital sign ranges

Back 3

Temperature Range: 36C-38C
Avg. oral/tympanic: 37C
Avg. rectal: 37.5C
Avg. axillary: 36.5C

Pulse:
60-100 bpm

Respiration:
12-20 breaths

Blood pressure:

Avg: 120/80 mmHg
Pulse Pressure: 30 to 50 mmHg

Front 4

core temperature?

Back 4

-temp. of deep tissues controlled by temp. controlled mechanisms

Front 5

What is the average temp. for healthy young adults?

Back 5

37

Front 6

Thermoregulation?

Back 6

Balance between heat lost and heat produced that is regulated by physiological and behavioural mechanisms.

Front 7

What does the hypothalamus do?

Back 7

The hypothalamus (located b/w the cerebral hemispheres) controls body temp. The anterior hypothalmus controls heat loss and the posterior hypothalmus controls heat production. (See p. 495 for more details of how it works).

Front 8

What produces heat production processes in the body?

Back 8

-Basal metabolic rate (BMR): accounts for heat produced at absolute rest and thyroid glands affect the BMR.

Shivering: involuntary body response to temperature differences in the body.

Nonshivering thermogenesis: occurs primarily in newborns.

Front 9

What produces heat loss processes?

Back 9

Radiation: transfer of heat from the surface of one object to the surface of another w/o direct contact b/w the two.

Conduction: transfer of heat from one object to the other.

Convection: transfer of heat away by air movement.

Evaporation: transfer of heat energy when liquid is changed to a gas

Diaphoresis: visible perspiration, prim. on forehead and upper thorax.

Front 10

How does skin regulate temperature?

Back 10

through insulation of body, vascoconstriction, and temperature sensation.

Front 11

Factors that affect body temperature

Back 11

-Age
-Excercise
-Hormone Level
-Circadian Rhythm
-Stress
-Environment
-Temperature Alterations

Front 12

What is pyrexia?

Back 12

Fever. Occurs when heat-loss mechanisms are unable to keep pace with excess heat production. Not harmful if stays below 39C.

Front 13

What is hyperthermia?

Back 13

body temp. that is elevated as a result if the body's inability to promote heat loss or reduce heat production. It's an overload of the body's thermoregulatory mechanisms

Front 14

What can lead to hyperthermia?

Back 14

-heatstroke (prolonged exposure to the sun or high environmental temp.).
-heat exhaustion (excess water and electrolyte loss from profuse disphoresis)

Front 15

What is hypothermia?

Back 15

-heat loss from prolonged exposure to cold overwhelms the ability to produce heat

Front 16

What is the equation to convert Fahrenheit to Celsius?

Back 16

(F-32) x 5/9

Front 17

What is the equation to convert Celsius to Fahrenheit?

Back 17

(C x 9/5) + 32

Front 18

Describe an electronic thermometer.

Back 18

-battery powered with display unit

- separate unbreakable probes available for oral (and axillary) and rectal use

-Also tympanic version

-advantage is that they are easily readible and read within seconds

2 modes: 4 sec. predictive & 3 min. standard

-signal sound when peak temp. reading has been measured.

Front 19

See p. 499 to 503 for different ways to measure body temperature

Back 19

See p. 499 to 503 for different ways to measure body temperature

Front 20

See p. 504 for a detailed list of advantages and disadvantages of select temperature measurement sites.

Back 20

See p. 504 for a detailed list of advantages and disadvantages of select temperature measurement sites.

Front 21

What are antipyretics?

Back 21

drugs that reduce fever.

Front 22

What id cardiac output?

Back 22

the volume of blood pumped by the heart during 1 minute

Front 23

What is the most common artery for taking pulse rate and why?

Back 23

radial artery because it is easily palpated.

Front 24

when is the cartoid artery assessed?

Back 24

When condition of the client suddenly changes--the heart will continue delivering blood through the cartoid artery to the brain.

Front 25

When do you use a stethoscope?

Back 25

When assessing the apical pulse rate

Front 26

See p. 511 to 514 for detailed descriptions on assessing the radial and apical pulses.

Back 26

See p. 511 to 514 for detailed descriptions on assessing the radial and apical pulses.

Front 27

What is the acceptable ranges if heart rate for an infant?

Back 27

120-160

Front 28

What is the acceptable ranges if heart rate for a toddler?

Back 28

90-140

Front 29

What is the acceptable ranges if heart rate for a preschooler?

Back 29

80-110

Front 30

What is the acceptable ranges if heart rate for a school-age child?

Back 30

75-100

Front 31

What is the acceptable ranges if heart rate for an adolescent?

Back 31

60-90

Front 32

What is the acceptable ranges if heart rate for an adult?

Back 32

60-100

Front 33

When do you assess the temporal artery?

Back 33

to assess pulse in children

Front 34

When do you assess brachial artery?

Back 34

to assess status of circulation of lower arm, to ausculate blood pressure

Front 35

When do you assess radial pulse?

Back 35

assess character of pulse peripherally and assess status of circulation to hand

Front 36

When do you assess ulnar artery?

Back 36

assess circulation of hand and perform the allen test

Front 37

When do you assess femoral artery?

Back 37

assess pulse during physiological shock or cardiac arrest when other pulses are not palable; assess status of circulation to the leg

Front 38

When do you assess popliteal artery?

Back 38

assess circulation of lower leg

Front 39

When do you assess posertial tibial?

Back 39

assess status of circulation to foot

Front 40

When do you assess dorsalis pedis?

Back 40

assess circulation to foot

Front 41

What are the characteristics of the pulse?

Back 41

Rate

Rhythm (normally there is a regular interval between each pulse or heart rate)

Strength

Equality (pulses on both side of peripheral vascular system should be assessed to compare

Front 42

Factors that influence character of respiration

Back 42

-Excerise
-Acute Pain
-Anxiety
-Smoking
-Body Position
-Medications
-Neurological injury
-Hemoglobin function

Front 43

What is respiration?

Back 43

the mechanism that the body uses to exchange gases b/w atomosphere and the blooed and b/w the blood and the cells

Front 44

What does respiration involve?

Back 44

Ventilation (movement of gases in and out of the lungs)

Diffusion (movement of oxygen and carbon dioxide b/w the alveoli and the red blood cells)

Perfusion (distribution of red blood cells to and from the pulmonary capillaries)

Front 45

What is hypoxemia?

Back 45

low levels of arterial O2 (which chemoreceptors in the carotid artery and arota signal the brain to increase the rate and depth of ventilation.

Front 46

Should you let a client know you are assess their respiration?

Back 46

No b/c they may change how they breath. Best time is right after assessing the radial pulse.